DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL
ID: C4RT
PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY
1. MEDICARE/MEDICAID PROVIDER NO.
245330
(L1)
(L4) 520 FIRST STREET NORTHEAST
2.STATE VENDOR OR MEDICAID NO.
(L2)
943188800
5. EFFECTIVE DATE CHANGE OF OWNERSHIP
01 Hospital
03/28/2016
8. ACCREDITATION STATUS:
0 Unaccredited
2 AOA
To
(b) :
05 HHA
09 ESRD
13 PTIP
02 SNF/NF/Dual
06 PRTF
10 NF
14 CORF
03 SNF/NF/Distinct
07 X-Ray
11 ICF/IID
15 ASC
04 SNF
08 OPT/SP
12 RHC
16 HOSPICE
2. Recertification
3. Termination
4. CHOW
5. Validation
6. Complaint
7. On-Site Visit
9. Other
FISCAL YEAR ENDING DATE:
(L35)
06/30
10.THE FACILITY IS CERTIFIED AS:
X A. In Compliance With
And/Or Approved Waivers Of The Following Requirements:
Program Requirements
Compliance Based On:
1. Acceptable POC
12.Total Facility Beds
165 (L18)
13.Total Certified Beds
165 (L17)
2. Technical Personnel
6. Scope of Services Limit
3. 24 Hour RN
7. Medical Director
4. 7-Day RN (Rural SNF)
8. Patient Room Size
5. Life Safety Code
9. Beds/Room
B. Not in Compliance with Program
Requirements and/or Applied Waivers:
(L12)
A*
* Code:
15. FACILITY MEETS
14. LTC CERTIFIED BED BREAKDOWN
18 SNF
1. Initial
8. Full Survey After Complaint
22 CLIA
(L34)
1 TJC
3 Other
7 (L8)
(L7)
(L10)
11. .LTC PERIOD OF CERTIFICATION
(a) :
02
7. PROVIDER/SUPPLIER CATEGORY
(L9)
From
(L6) 56377
(L5) SARTELL, MN
6. DATE OF SURVEY
Facility ID: 00627
4. TYPE OF ACTION:
3. NAME AND ADDRESS OF FACILITY
(L3) COUNTRY MANOR HEALTH & REHAB CTR
18/19 SNF
19 SNF
ICF
IID
(L39)
(L42)
(L43)
(L15)
1861 (e) (1) or 1861 (j) (1):
165
(L37)
(L38)
16. STATE SURVEY AGENCY REMARKS (IF APPLICABLE SHOW LTC CANCELLATION DATE):
17. SURVEYOR SIGNATURE
Date :
Austin Fry, HFE NE II
18. STATE SURVEY AGENCY APPROVAL
03/28/2016
(L19)
Date:
Kate JohnsTon, Program Specialist
04/08/2016
(L20)
PART II - TO BE COMPLETED BY HCFA REGIONAL OFFICE OR SINGLE STATE AGENCY
19. DETERMINATION OF ELIGIBILITY
X
20. COMPLIANCE WITH CIVIL
RIGHTS ACT:
1. Facility is Eligible to Participate
21.
1. Statement of Financial Solvency (HCFA-2572)
2. Ownership/Control Interest Disclosure Stmt (HCFA-1513)
3. Both of the Above :
2. Facility is not Eligible
(L21)
22. ORIGINAL DATE
23. LTC AGREEMENT
24. LTC AGREEMENT
BEGINNING DATE
OF PARTICIPATION
26. TERMINATION ACTION:
ENDING DATE
VOLUNTARY
07/01/1986
(L24)
(L41)
25. LTC EXTENSION DATE:
(L25)
(L30)
00
05-Fail to Meet Health/Safety
02-Dissatisfaction W/ Reimbursement
06-Fail to Meet Agreement
03-Risk of Involuntary Termination
27. ALTERNATIVE SANCTIONS
04-Other Reason for Withdrawal
A. Suspension of Admissions:
OTHER
07-Provider Status Change
00-Active
(L44)
(L27)
INVOLUNTARY
01-Merger, Closure
B. Rescind Suspension Date:
(L45)
28. TERMINATION DATE:
30. REMARKS
29. INTERMEDIARY/CARRIER NO.
03001
(L28)
31. RO RECEIPT OF CMS-1539
(L31)
32. DETERMINATION OF APPROVAL DATE
04/05/2016
(L32)
FORM CMS-1539 (7-84) (Destroy Prior Editions)
(L33)
DETERMINATION APPROVAL
020499
WZKdd/E'͕D/Ed/E/E'E/DWZKs/E'd,,>d,K&>>D/EE^KdE^
D^ĞƌƚŝĨŝĐĂƚŝŽŶEƵŵďĞƌ;EͿ͗ϮϰϱϯϯϬ Ɖƌŝůϴ͕ϮϬϭϲ
Dƌ͘ƌŝĂŶ<Ğůŵ͕ĚŵŝŶŝƐƚƌĂƚŽƌ
ŽƵŶƚƌLJDĂŶŽƌ,ĞĂůƚŚΘZĞŚĂďĞŶƚĞƌ
ϱϮϬ&ŝƌƐƚ^ƚƌĞĞƚEŽƌƚŚĞĂƐƚ
^ĂƌƚĞůů͕DŝŶŶĞƐŽƚĂϱϲϯϳϳ
ĞĂƌDƌ͘<Ğůŵ͗
dŚĞDŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚĂƐƐŝƐƚƐƚŚĞĞŶƚĞƌƐĨŽƌDĞĚŝĐĂƌĞĂŶĚDĞĚŝĐĂŝĚ^ĞƌǀŝĐĞƐ;D^ͿďLJ
ƐƵƌǀĞLJŝŶŐƐŬŝůůĞĚŶƵƌƐŝŶŐĨĂĐŝůŝƚŝĞƐĂŶĚŶƵƌƐŝŶŐĨĂĐŝůŝƚŝĞƐƚŽĚĞƚĞƌŵŝŶĞǁŚĞƚŚĞƌƚŚĞLJŵĞĞƚƚŚĞ
ƌĞƋƵŝƌĞŵĞŶƚƐĨŽƌƉĂƌƚŝĐŝƉĂƚŝŽŶ͘dŽƉĂƌƚŝĐŝƉĂƚĞĂƐĂƐŬŝůůĞĚŶƵƌƐŝŶŐĨĂĐŝůŝƚLJŝŶƚŚĞDĞĚŝĐĂƌĞƉƌŽŐƌĂŵŽƌĂƐ
ĂŶƵƌƐŝŶŐĨĂĐŝůŝƚLJŝŶƚŚĞDĞĚŝĐĂŝĚƉƌŽŐƌĂŵ͕ĂƉƌŽǀŝĚĞƌŵƵƐƚďĞŝŶƐƵďƐƚĂŶƚŝĂůĐŽŵƉůŝĂŶĐĞǁŝƚŚĞĂĐŚŽĨ
ƚŚĞƌĞƋƵŝƌĞŵĞŶƚƐĞƐƚĂďůŝƐŚĞĚďLJƚŚĞ^ĞĐƌĞƚĂƌLJŽĨ,ĞĂůƚŚĂŶĚ,ƵŵĂŶ^ĞƌǀŝĐĞƐĨŽƵŶĚŝŶϰϮ&ZƉĂƌƚϰϴϯ͕
^ƵďƉĂƌƚ͘ ĂƐĞĚƵƉŽŶLJŽƵƌĨĂĐŝůŝƚLJďĞŝŶŐŝŶƐƵďƐƚĂŶƚŝĂůĐŽŵƉůŝĂŶĐĞ͕ǁĞĂƌĞƌĞĐŽŵŵĞŶĚŝŶŐƚŽD^ƚŚĂƚLJŽƵƌ
ĨĂĐŝůŝƚLJďĞƌĞĐĞƌƚŝĨŝĞĚĨŽƌƉĂƌƚŝĐŝƉĂƚŝŽŶŝŶƚŚĞDĞĚŝĐĂƌĞĂŶĚDĞĚŝĐĂŝĚƉƌŽŐƌĂŵ͘
ĨĨĞĐƚŝǀĞDĂƌĐŚϮϱ͕ϮϬϭϲƚŚĞĂďŽǀĞĨĂĐŝůŝƚLJŝƐĐĞƌƚŝĨŝĞĚĨŽƌŽƌƌĞĐŽŵŵĞŶĚĞĚĨŽƌ͗ ϭϲϱ
^ŬŝůůĞĚEƵƌƐŝŶŐ&ĂĐŝůŝƚLJͬEƵƌƐŝŶŐ&ĂĐŝůŝƚLJĞĚƐ
zŽƵƌĨĂĐŝůŝƚLJ͛ƐDĞĚŝĐĂƌĞĂƉƉƌŽǀĞĚĂƌĞĂĐŽŶƐŝƐƚƐŽĨĂůůϭϲϱƐŬŝůůĞĚŶƵƌƐŝŶŐĨĂĐŝůŝƚLJďĞĚƐ͘
zŽƵƐŚŽƵůĚĂĚǀŝƐĞŽƵƌŽĨĨŝĐĞŽĨĂŶLJĐŚĂŶŐĞƐŝŶƐƚĂĨĨŝŶŐ͕ƐĞƌǀŝĐĞƐ͕ŽƌŽƌŐĂŶŝnjĂƚŝŽŶ͕ǁŚŝĐŚŵŝŐŚƚĂĨĨĞĐƚ
LJŽƵƌĐĞƌƚŝĨŝĐĂƚŝŽŶƐƚĂƚƵƐ͘
/Ĩ͕ĂƚƚŚĞƚŝŵĞŽĨLJŽƵƌŶĞdžƚƐƵƌǀĞLJ͕ǁĞĨŝŶĚLJŽƵƌĨĂĐŝůŝƚLJƚŽŶŽƚďĞŝŶƐƵďƐƚĂŶƚŝĂůĐŽŵƉůŝĂŶĐĞLJŽƵƌ
DĞĚŝĐĂƌĞĂŶĚDĞĚŝĐĂŝĚƉƌŽǀŝĚĞƌĂŐƌĞĞŵĞŶƚŵĂLJďĞƐƵďũĞĐƚƚŽŶŽŶͲƌĞŶĞǁĂůŽƌƚĞƌŵŝŶĂƚŝŽŶ͘
WůĞĂƐĞĐŽŶƚĂĐƚŵĞŝĨLJŽƵŚĂǀĞĂŶLJƋƵĞƐƚŝŽŶƐ͘
ŶĞƋƵĂůŽƉƉŽƌƚƵŶŝƚLJĞŵƉůŽLJĞƌ
ŽƵŶƚƌLJDĂŶŽƌ,ĞĂůƚŚΘZĞŚĂďƚƌ
Ɖƌŝůϴ͕ϮϬϭϲ
WĂŐĞϮ
^ŝŶĐĞƌĞůLJ͕
<ĂƚĞ:ŽŚŶƐdŽŶ͕WƌŽŐƌĂŵ^ƉĞĐŝĂůŝƐƚ
WƌŽŐƌĂŵƐƐƵƌĂŶĐĞhŶŝƚ
>ŝĐĞŶƐŝŶŐĂŶĚĞƌƚŝĨŝĐĂƚŝŽŶWƌŽŐƌĂŵ
,ĞĂůƚŚZĞŐƵůĂƚŝŽŶŝǀŝƐŝŽŶ ϴϱĂƐƚ^ĞǀĞŶƚŚWůĂĐĞ͕^ƵŝƚĞϮϮϬ
W͘K͘ŽdžϲϰϵϬϬ
^ƚ͘WĂƵů͕DŝŶŶĞƐŽƚĂϱϱϭϲϰͲϬϵϬϬ
ŬĂƚĞ͘ũŽŚŶƐƚŽŶΛƐƚĂƚĞ͘ŵŶ͘ƵƐ
dĞůĞƉŚŽŶĞ͗;ϲϱϭͿϮϬϭͲϯϵϵϮ&Ădž͗;ϲϱϭͿϮϭϱͲϵϲϵϳ
ĐĐ͗
>ŝĐĞŶƐŝŶŐĂŶĚĞƌƚŝĨŝĐĂƚŝŽŶ&ŝůĞ
WZKdd/E'͕D/Ed/E/E'E/DWZKs/E'd,,>d,K&>>D/EE^KdE^
Ɖƌŝůϴ͕ϮϬϭϲ
Dƌ͘ƌŝĂŶ<Ğůŵ͕ĚŵŝŶŝƐƚƌĂƚŽƌ
ŽƵŶƚƌLJDĂŶŽƌ,ĞĂůƚŚΘZĞŚĂďĞŶƚĞƌ
ϱϮϬ&ŝƌƐƚ^ƚƌĞĞƚEŽƌƚŚĞĂƐƚ
^ĂƌƚĞůů͕DŝŶŶĞƐŽƚĂϱϲϯϳϳ
Z͗WƌŽũĞĐƚEƵŵďĞƌ^ϱϯϯϬϬϮϲ
ĞĂƌDƌ͘<Ğůŵ͗
KŶDĂƌĐŚϭ͕ϮϬϭϲ͕ǁĞŝŶĨŽƌŵĞĚLJŽƵƚŚĂƚǁĞǁŽƵůĚƌĞĐŽŵŵĞŶĚĞŶĨŽƌĐĞŵĞŶƚƌĞŵĞĚŝĞƐďĂƐĞĚŽŶƚŚĞ
ĚĞĨŝĐŝĞŶĐŝĞƐĐŝƚĞĚďLJƚŚŝƐĞƉĂƌƚŵĞŶƚĨŽƌĂƐƚĂŶĚĂƌĚƐƵƌǀĞLJ͕ĐŽŵƉůĞƚĞĚŽŶ&ĞďƌƵĂƌLJϮϰ͕ϮϬϭϲ͘dŚŝƐ
ƐƵƌǀĞLJĨŽƵŶĚƚŚĞŵŽƐƚƐĞƌŝŽƵƐĚĞĨŝĐŝĞŶĐŝĞƐƚŽďĞŝƐŽůĂƚĞĚĚĞĨŝĐŝĞŶĐŝĞƐƚŚĂƚĐŽŶƐƚŝƚƵƚĞĚŶŽĂĐƚƵĂůŚĂƌŵ
ǁŝƚŚƉŽƚĞŶƚŝĂůĨŽƌŵŽƌĞƚŚĂŶŵŝŶŝŵĂůŚĂƌŵƚŚĂƚǁĂƐŶŽƚŝŵŵĞĚŝĂƚĞũĞŽƉĂƌĚLJ;>ĞǀĞůͿǁŚĞƌĞďLJ
ĐŽƌƌĞĐƚŝŽŶƐǁĞƌĞƌĞƋƵŝƌĞĚ͘
KŶDĂƌĐŚϮϴ͕ϮϬϭϲ͕ƚŚĞDŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚĐŽŵƉůĞƚĞĚĂWŽƐƚĞƌƚŝĨŝĐĂƚŝŽŶZĞǀŝƐŝƚ;WZͿ ĂŶĚŽŶƉƌŝůϭ͕ϮϬϭϲƚŚĞDŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨWƵďůŝĐ^ĂĨĞƚLJĐŽŵƉůĞƚĞĚĂWZƚŽǀĞƌŝĨLJƚŚĂƚLJŽƵƌ
ĨĂĐŝůŝƚLJŚĂĚĂĐŚŝĞǀĞĚĂŶĚŵĂŝŶƚĂŝŶĞĚĐŽŵƉůŝĂŶĐĞǁŝƚŚĨĞĚĞƌĂůĐĞƌƚŝĨŝĐĂƚŝŽŶĚĞĨŝĐŝĞŶĐŝĞƐŝƐƐƵĞĚƉƵƌƐƵĂŶƚ
ƚŽĂƐƚĂŶĚĂƌĚƐƵƌǀĞLJ͕ĐŽŵƉůĞƚĞĚŽŶ&ĞďƌƵĂƌLJϮϰ͕ϮϬϭϲ͘tĞƉƌĞƐƵŵĞĚ͕ďĂƐĞĚŽŶLJŽƵƌƉůĂŶŽĨ
ĐŽƌƌĞĐƚŝŽŶ͕ƚŚĂƚLJŽƵƌĨĂĐŝůŝƚLJŚĂĚĐŽƌƌĞĐƚĞĚƚŚĞƐĞĚĞĨŝĐŝĞŶĐŝĞƐĂƐŽĨDĂƌĐŚϮϱ͕ϮϬϭϲ͘ĂƐĞĚŽŶŽƵƌWZ͕
ǁĞŚĂǀĞĚĞƚĞƌŵŝŶĞĚƚŚĂƚLJŽƵƌĨĂĐŝůŝƚLJŚĂƐĐŽƌƌĞĐƚĞĚƚŚĞĚĞĨŝĐŝĞŶĐŝĞƐŝƐƐƵĞĚƉƵƌƐƵĂŶƚƚŽŽƵƌƐƚĂŶĚĂƌĚ
ƐƵƌǀĞLJ͕ĐŽŵƉůĞƚĞĚŽŶ&ĞďƌƵĂƌLJϮϰ͕ϮϬϭϲ͕ĞĨĨĞĐƚŝǀĞDĂƌĐŚϮϱ͕ϮϬϭϲĂŶĚƚŚĞƌĞĨŽƌĞƌĞŵĞĚŝĞƐŽƵƚůŝŶĞĚŝŶ
ŽƵƌůĞƚƚĞƌƚŽLJŽƵĚĂƚĞĚDĂƌĐŚϭ͕ϮϬϭϲ͕ǁŝůůŶŽƚďĞŝŵƉŽƐĞĚ͘
WůĞĂƐĞŶŽƚĞ͕ŝƚŝƐLJŽƵƌƌĞƐƉŽŶƐŝďŝůŝƚLJƚŽƐŚĂƌĞƚŚĞŝŶĨŽƌŵĂƚŝŽŶĐŽŶƚĂŝŶĞĚŝŶƚŚŝƐůĞƚƚĞƌĂŶĚƚŚĞƌĞƐƵůƚƐŽĨ
ƚŚŝƐǀŝƐŝƚǁŝƚŚƚŚĞWƌĞƐŝĚĞŶƚŽĨLJŽƵƌĨĂĐŝůŝƚLJΖƐ'ŽǀĞƌŶŝŶŐŽĚLJ͘
ŶĐůŽƐĞĚŝƐĂĐŽƉLJŽĨƚŚĞWŽƐƚĞƌƚŝĨŝĐĂƚŝŽŶZĞǀŝƐŝƚ&Žƌŵ͕;D^ͲϮϱϲϳͿĨƌŽŵƚŚŝƐǀŝƐŝƚ͘ &ĞĞůĨƌĞĞƚŽĐŽŶƚĂĐƚŵĞŝĨLJŽƵŚĂǀĞƋƵĞƐƚŝŽŶƐ͘
ŶĞƋƵĂůŽƉƉŽƌƚƵŶŝƚLJĞŵƉůŽLJĞƌ͘
ŽƵŶƚƌLJDĂŶŽƌ,ĞĂůƚŚΘZĞŚĂďƚƌ
Ɖƌŝůϴ͕ϮϬϭϲ
WĂŐĞϮ
^ŝŶĐĞƌĞůLJ͕
<ĂƚĞ:ŽŚŶƐdŽŶ͕WƌŽŐƌĂŵ^ƉĞĐŝĂůŝƐƚ
WƌŽŐƌĂŵƐƐƵƌĂŶĐĞhŶŝƚ
>ŝĐĞŶƐŝŶŐĂŶĚĞƌƚŝĨŝĐĂƚŝŽŶWƌŽŐƌĂŵ
,ĞĂůƚŚZĞŐƵůĂƚŝŽŶŝǀŝƐŝŽŶ ϴϱĂƐƚ^ĞǀĞŶƚŚWůĂĐĞ͕^ƵŝƚĞϮϮϬ
W͘K͘ŽdžϲϰϵϬϬ
^ƚ͘WĂƵů͕DŝŶŶĞƐŽƚĂϱϱϭϲϰͲϬϵϬϬ
ŬĂƚĞ͘ũŽŚŶƐƚŽŶΛƐƚĂƚĞ͘ŵŶ͘ƵƐ
dĞůĞƉŚŽŶĞ͗;ϲϱϭͿϮϬϭͲϯϵϵϮ&Ădž͗;ϲϱϭͿϮϭϱͲϵϲϵϳ
ŶĐůŽƐƵƌĞ
ĐĐ͗>ŝĐĞŶƐŝŶŐĂŶĚĞƌƚŝĨŝĐĂƚŝŽŶ&ŝůĞ DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
POST-CERTIFICATION REVISIT REPORT
PROVIDER / SUPPLIER / CLIA /
IDENTIFICATION NUMBER
245330
Y1
MULTIPLE CONSTRUCTION
A. Building
B. Wing
DATE OF REVISIT
Y2
NAME OF FACILITY
STREET ADDRESS, CITY, STATE, ZIP CODE
COUNTRY MANOR HEALTH & REHAB CTR
520 FIRST STREET NORTHEAST
3/28/2016
Y3
SARTELL, MN 56377
This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments
program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan of Correction, that have been
corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC
provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on
the survey report form).
ITEM
DATE
ITEM
Y4
Y5
Y4
ID Prefix
F0154
Correction
ID Prefix
Reg. #
483.10(b)(3), 483.10(d)
(2)
Completed
Reg. #
LSC
03/25/2016
ID Prefix
Reg. #
DATE
Y5
ITEM
DATE
Y4
Y5
Correction
ID Prefix
Correction
Completed
Reg. #
Completed
LSC
03/25/2016
LSC
Correction
ID Prefix
Correction
ID Prefix
Correction
Completed
Reg. #
Completed
Reg. #
Completed
LSC
F0356
483.30(e)
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
REVIEWED BY
STATE AGENCY
REVIEWED BY
(INITIALS)
REVIEWED BY
CMS RO
REVIEWED BY
(INITIALS)
JS/KJ
FOLLOWUP TO SURVEY COMPLETED ON
2/24/2016
Form CMS - 2567B (09/92) EF (11/06)
LSC
DATE
SIGNATURE OF SURVEYOR
DATE
DATE
33925
04/08/2016
03/28/2016
TITLE
DATE
CHECK FOR ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY OF
UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE FACILITY?
Page 1 of 1
EVENT ID:
YES
C4RT12
NO
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
POST-CERTIFICATION REVISIT REPORT
PROVIDER / SUPPLIER / CLIA /
IDENTIFICATION NUMBER
245330
Y1
MULTIPLE CONSTRUCTION
A. Building 01 - MAIN BUILDING
B. Wing
DATE OF REVISIT
Y2
NAME OF FACILITY
STREET ADDRESS, CITY, STATE, ZIP CODE
COUNTRY MANOR HEALTH & REHAB CTR
520 FIRST STREET NORTHEAST
4/1/2016
Y3
SARTELL, MN 56377
This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments
program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan of Correction, that have been
corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC
provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on
the survey report form).
ITEM
DATE
ITEM
Y4
Y5
Y4
ID Prefix
DATE
Y5
ITEM
DATE
Y4
Y5
Correction
ID Prefix
Correction
ID Prefix
Correction
Completed
Reg. #
Completed
Reg. #
Completed
03/18/2016
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
Reg. #
LSC
NFPA 101
K0056
LSC
LSC
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
REVIEWED BY
STATE AGENCY
REVIEWED BY
(INITIALS)
REVIEWED BY
CMS RO
REVIEWED BY
(INITIALS)
TL/KJ
FOLLOWUP TO SURVEY COMPLETED ON
2/22/2016
Form CMS - 2567B (09/92) EF (11/06)
LSC
DATE
SIGNATURE OF SURVEYOR
DATE
DATE
27200
04/08/2016
04/01/2016
TITLE
DATE
CHECK FOR ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY OF
UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE FACILITY?
Page 1 of 1
EVENT ID:
YES
C4RT22
NO
WZKdd/E'͕D/Ed/E/E'E/DWZKs/E'd,,>d,K&>>D/EE^KdE^
Ɖƌŝůϴ͕ϮϬϭϲ
Dƌ͘ƌŝĂŶ<Ğůŵ͕ĚŵŝŶŝƐƚƌĂƚŽƌ
ŽƵŶƚƌLJDĂŶŽƌ,ĞĂůƚŚΘZĞŚĂďĞŶƚĞƌ
ϱϮϬ&ŝƌƐƚ^ƚƌĞĞƚEŽƌƚŚĞĂƐƚ
^ĂƌƚĞůů͕DŝŶŶĞƐŽƚĂϱϲϯϳϳ
ZĞ͗ŶĐůŽƐĞĚZĞŝŶƐƉĞĐƚŝŽŶZĞƐƵůƚƐͲWƌŽũĞĐƚEƵŵďĞƌ^ϱϯϯϬϬϮϲ
ĞĂƌDƌ͘<Ğůŵ͗
KŶDĂƌĐŚϮϴ͕ϮϬϭϲƐƵƌǀĞLJƐƚĂĨĨŽĨƚŚĞDŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚ͕>ŝĐĞŶƐŝŶŐĂŶĚĞƌƚŝĨŝĐĂƚŝŽŶ
WƌŽŐƌĂŵĐŽŵƉůĞƚĞĚĂƌĞŝŶƐƉĞĐƚŝŽŶŽĨLJŽƵƌĨĂĐŝůŝƚLJ͕ƚŽĚĞƚĞƌŵŝŶĞĐŽƌƌĞĐƚŝŽŶŽĨŽƌĚĞƌƐĨŽƵŶĚŽŶƚŚĞ
ƐƵƌǀĞLJĐŽŵƉůĞƚĞĚŽŶ&ĞďƌƵĂƌLJϮϰ͕ϮϬϭϲ͕ǁŝƚŚŽƌĚĞƌƐƌĞĐĞŝǀĞĚďLJLJŽƵŽŶDĂƌĐŚϰ͕ϮϬϭϲ͘ƚƚŚŝƐƚŝŵĞ
ƚŚĞƐĞĐŽƌƌĞĐƚŝŽŶŽƌĚĞƌƐǁĞƌĞĨŽƵŶĚĐŽƌƌĞĐƚĞĚĂŶĚĂƌĞůŝƐƚĞĚŽŶƚŚĞĂƚƚĂĐŚĞĚZĞǀŝƐŝƚZĞƉŽƌƚ&Žƌŵ͘
WůĞĂƐĞŶŽƚĞ͕ŝƚŝƐLJŽƵƌƌĞƐƉŽŶƐŝďŝůŝƚLJƚŽƐŚĂƌĞƚŚĞŝŶĨŽƌŵĂƚŝŽŶĐŽŶƚĂŝŶĞĚŝŶƚŚŝƐůĞƚƚĞƌĂŶĚƚŚĞƌĞƐƵůƚƐŽĨ
ƚŚŝƐǀŝƐŝƚǁŝƚŚƚŚĞWƌĞƐŝĚĞŶƚŽĨLJŽƵƌĨĂĐŝůŝƚLJ͛Ɛ'ŽǀĞƌŶŝŶŐŽĚLJ͘
WůĞĂƐĞĨĞĞůĨƌĞĞƚŽĐĂůůŵĞǁŝƚŚĂŶLJƋƵĞƐƚŝŽŶƐ͘
^ŝŶĐĞƌĞůLJ͕
<ĂƚĞ:ŽŚŶƐdŽŶ͕WƌŽŐƌĂŵ^ƉĞĐŝĂůŝƐƚ
WƌŽŐƌĂŵƐƐƵƌĂŶĐĞhŶŝƚ
>ŝĐĞŶƐŝŶŐĂŶĚĞƌƚŝĨŝĐĂƚŝŽŶWƌŽŐƌĂŵ
,ĞĂůƚŚZĞŐƵůĂƚŝŽŶŝǀŝƐŝŽŶ ϴϱĂƐƚ^ĞǀĞŶƚŚWůĂĐĞ͕^ƵŝƚĞϮϮϬ
W͘K͘ŽdžϲϰϵϬϬ
^ƚ͘WĂƵů͕DŝŶŶĞƐŽƚĂϱϱϭϲϰͲϬϵϬϬ
ŬĂƚĞ͘ũŽŚŶƐƚŽŶΛƐƚĂƚĞ͘ŵŶ͘ƵƐ
dĞůĞƉŚŽŶĞ͗;ϲϱϭͿϮϬϭͲϯϵϵϮ&Ădž͗;ϲϱϭͿϮϭϱͲϵϲϵϳ
ŶĐůŽƐƵƌĞ;ƐͿ
ĐĐ͗ KƌŝŐŝŶĂůͲ&ĂĐŝůŝƚLJ >ŝĐĞŶƐŝŶŐĂŶĚĞƌƚŝĨŝĐĂƚŝŽŶ&ŝůĞ
ŶĞƋƵĂůŽƉƉŽƌƚƵŶŝƚLJĞŵƉůŽLJĞƌ
STATE FORM: REVISIT REPORT
PROVIDER / SUPPLIER / CLIA /
IDENTIFICATION NUMBER
00627
Y1
MULTIPLE CONSTRUCTION
A. Building
B. Wing
DATE OF REVISIT
Y2
NAME OF FACILITY
STREET ADDRESS, CITY, STATE, ZIP CODE
COUNTRY MANOR HEALTH & REHAB CTR
520 FIRST STREET NORTHEAST
3/28/2016
Y3
SARTELL, MN 56377
This report is completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such
corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC provision number and the
identification prefix code previously shown on the State Survey Report (prefix codes shown to the left of each requirement on the survey
report form).
ITEM
DATE
ITEM
Y4
Y5
Y4
DATE
Y5
ITEM
DATE
Y4
Y5
ID Prefix
21426
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
MN St. Statute 144A.04
Subd. 3
Completed
Reg. #
Completed
Reg. #
Completed
LSC
03/25/2016
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
REVIEWED BY
STATE AGENCY
REVIEWED BY
(INITIALS)
REVIEWED BY
CMS RO
REVIEWED BY
(INITIALS)
JS/KJ
FOLLOWUP TO SURVEY COMPLETED ON
2/24/2016
LSC
DATE
SIGNATURE OF SURVEYOR
04/08/2016
DATE
(11/06)
03/28/2016
TITLE
DATE
CHECK FOR ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY OF
UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE FACILITY?
Page 1 of 1
STATE FORM: REVISIT REPORT
DATE
33925
EVENT ID:
YES
C4RT12
NO
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL
ID: C4RT
PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY
1. MEDICARE/MEDICAID PROVIDER NO.
245330
(L1)
(L4) 520 FIRST STREET NORTHEAST
2.STATE VENDOR OR MEDICAID NO.
(L2)
943188800
5. EFFECTIVE DATE CHANGE OF OWNERSHIP
02/24/2016
8. ACCREDITATION STATUS:
0 Unaccredited
2 AOA
05 HHA
09 ESRD
13 PTIP
(L34)
02 SNF/NF/Dual
06 PRTF
10 NF
14 CORF
(L10)
03 SNF/NF/Distinct
07 X-Ray
11 ICF/IID
15 ASC
04 SNF
08 OPT/SP
12 RHC
16 HOSPICE
1 TJC
3 Other
To
(b) :
1. Initial
2. Recertification
3. Termination
4. CHOW
5. Validation
6. Complaint
7. On-Site Visit
9. Other
8. Full Survey After Complaint
22 CLIA
FISCAL YEAR ENDING DATE:
(L35)
06/30
10.THE FACILITY IS CERTIFIED AS:
A. In Compliance With
And/Or Approved Waivers Of The Following Requirements:
Program Requirements
Compliance Based On:
1. Acceptable POC
12.Total Facility Beds
165 (L18)
13.Total Certified Beds
165 (L17)
X B. Not in Compliance with Program
Requirements and/or Applied Waivers:
2. Technical Personnel
6. Scope of Services Limit
3. 24 Hour RN
7. Medical Director
4. 7-Day RN (Rural SNF)
8. Patient Room Size
5. Life Safety Code
9. Beds/Room
(L12)
B*
* Code:
15. FACILITY MEETS
14. LTC CERTIFIED BED BREAKDOWN
18 SNF
2 (L8)
(L7)
01 Hospital
11. .LTC PERIOD OF CERTIFICATION
(a) :
02
7. PROVIDER/SUPPLIER CATEGORY
(L9)
From
(L6) 56377
(L5) SARTELL, MN
6. DATE OF SURVEY
Facility ID: 00627
4. TYPE OF ACTION:
3. NAME AND ADDRESS OF FACILITY
(L3) COUNTRY MANOR HEALTH & REHAB CTR
18/19 SNF
19 SNF
ICF
IID
(L39)
(L42)
(L43)
(L15)
1861 (e) (1) or 1861 (j) (1):
165
(L37)
(L38)
16. STATE SURVEY AGENCY REMARKS (IF APPLICABLE SHOW LTC CANCELLATION DATE):
17. SURVEYOR SIGNATURE
Date :
Annette Truebenbach, HFE NE II
18. STATE SURVEY AGENCY APPROVAL
03/16/2016
(L19)
Date:
Kate JohnsTon, Program Specialist
04/05/2016
(L20)
PART II - TO BE COMPLETED BY HCFA REGIONAL OFFICE OR SINGLE STATE AGENCY
19. DETERMINATION OF ELIGIBILITY
20. COMPLIANCE WITH CIVIL
RIGHTS ACT:
1. Facility is Eligible to Participate
21.
1. Statement of Financial Solvency (HCFA-2572)
2. Ownership/Control Interest Disclosure Stmt (HCFA-1513)
3. Both of the Above :
2. Facility is not Eligible
(L21)
22. ORIGINAL DATE
23. LTC AGREEMENT
OF PARTICIPATION
24. LTC AGREEMENT
BEGINNING DATE
26. TERMINATION ACTION:
ENDING DATE
VOLUNTARY
07/01/1986
(L24)
(L41)
25. LTC EXTENSION DATE:
(L25)
(L30)
00
05-Fail to Meet Health/Safety
02-Dissatisfaction W/ Reimbursement
06-Fail to Meet Agreement
03-Risk of Involuntary Termination
27. ALTERNATIVE SANCTIONS
04-Other Reason for Withdrawal
A. Suspension of Admissions:
OTHER
07-Provider Status Change
00-Active
(L44)
(L27)
INVOLUNTARY
01-Merger, Closure
B. Rescind Suspension Date:
(L45)
28. TERMINATION DATE:
30. REMARKS
29. INTERMEDIARY/CARRIER NO.
03001
(L28)
31. RO RECEIPT OF CMS-1539
3RVWHG&R
32. DETERMINATION OF APPROVAL DATE
(L32)
FORM CMS-1539 (7-84) (Destroy Prior Editions)
(L31)
(L33)
DETERMINATION APPROVAL
020499
WZKdd/E'͕D/Ed/E/E'E/DWZKs/E'd,,>d,K&>>D/EE^KdE^
ĞƌƚŝĨŝĞĚDĂŝůηϳϬϭϭϬϰϳϬϬϬϬϬϱϮϲϮϮϳϲϮ
DĂƌĐŚϭ͕ϮϬϭϲ
Dƌ͘ƌŝĂŶ<Ğůŵ͕ĚŵŝŶŝƐƚƌĂƚŽƌ
ŽƵŶƚƌLJDĂŶŽƌ,ĞĂůƚŚΘZĞŚĂďŝůŝƚĂƚŝŽŶĞŶƚĞƌ
ϱϮϬ&ŝƌƐƚ^ƚƌĞĞƚEŽƌƚŚĞĂƐƚ
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Z͗WƌŽũĞĐƚEƵŵďĞƌ^ϱϯϯϬϬϮϲ
ĞĂƌDƌ͘<Ğůŵ͗
KŶ&ĞďƌƵĂƌLJϮϰ͕ϮϬϭϲ͕ĂƐƚĂŶĚĂƌĚƐƵƌǀĞLJǁĂƐĐŽŵƉůĞƚĞĚĂƚLJŽƵƌĨĂĐŝůŝƚLJďLJƚŚĞDŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚƐ
ŽĨ,ĞĂůƚŚĂŶĚWƵďůŝĐ^ĂĨĞƚLJƚŽĚĞƚĞƌŵŝŶĞŝĨLJŽƵƌĨĂĐŝůŝƚLJǁĂƐŝŶĐŽŵƉůŝĂŶĐĞǁŝƚŚ&ĞĚĞƌĂůƉĂƌƚŝĐŝƉĂƚŝŽŶ
ƌĞƋƵŝƌĞŵĞŶƚƐĨŽƌƐŬŝůůĞĚŶƵƌƐŝŶŐĨĂĐŝůŝƚŝĞƐĂŶĚͬŽƌŶƵƌƐŝŶŐĨĂĐŝůŝƚŝĞƐƉĂƌƚŝĐŝƉĂƚŝŶŐŝŶƚŚĞDĞĚŝĐĂƌĞĂŶĚͬŽƌ
DĞĚŝĐĂŝĚƉƌŽŐƌĂŵƐ͘dŚŝƐƐƵƌǀĞLJĨŽƵŶĚƚŚĞŵŽƐƚƐĞƌŝŽƵƐĚĞĨŝĐŝĞŶĐŝĞƐŝŶLJŽƵƌĨĂĐŝůŝƚLJƚŽďĞŝƐŽůĂƚĞĚ
ĚĞĨŝĐŝĞŶĐŝĞƐƚŚĂƚĐŽŶƐƚŝƚƵƚĞŶŽĂĐƚƵĂůŚĂƌŵǁŝƚŚƉŽƚĞŶƚŝĂůĨŽƌŵŽƌĞƚŚĂŶŵŝŶŝŵĂůŚĂƌŵƚŚĂƚŝƐŶŽƚ
ŝŵŵĞĚŝĂƚĞũĞŽƉĂƌĚLJ;>ĞǀĞůͿ͕ĂƐĞǀŝĚĞŶĐĞĚďLJƚŚĞĂƚƚĂĐŚĞĚD^ͲϮϱϲϳǁŚĞƌĞďLJĐŽƌƌĞĐƚŝŽŶƐĂƌĞ
ƌĞƋƵŝƌĞĚ͘ĐŽƉLJŽĨƚŚĞ^ƚĂƚĞŵĞŶƚŽĨĞĨŝĐŝĞŶĐŝĞƐ;D^ͲϮϱϲϳͿŝƐĞŶĐůŽƐĞĚ͘/ŶĂĚĚŝƚŝŽŶ͕ĂƚƚŚĞƚŝŵĞŽĨ
ƚŚĞ&ĞďƌƵĂƌLJϮϰ͕ϮϬϭϲƐƚĂŶĚĂƌĚƐƵƌǀĞLJƚŚĞDŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚĐŽŵƉůĞƚĞĚĂŶ
ŝŶǀĞƐƚŝŐĂƚŝŽŶŽĨĐŽŵƉůĂŝŶƚŶƵŵďĞƌ,ϱϯϯϬϬϮϮƚŚĂƚǁĂƐĨŽƵŶĚƚŽďĞƵŶƐƵďƐƚĂŶƚŝĂƚĞĚ͘
WůĞĂƐĞŶŽƚĞƚŚĂƚƚŚŝƐŶŽƚŝĐĞĚŽĞƐŶŽƚĐŽŶƐƚŝƚƵƚĞĨŽƌŵĂůŶŽƚŝĐĞŽĨŝŵƉŽƐŝƚŝŽŶŽĨĂůƚĞƌŶĂƚŝǀĞƌĞŵĞĚŝĞƐŽƌ
ƚĞƌŵŝŶĂƚŝŽŶŽĨLJŽƵƌƉƌŽǀŝĚĞƌĂŐƌĞĞŵĞŶƚ͘^ŚŽƵůĚƚŚĞĞŶƚĞƌƐĨŽƌDĞĚŝĐĂƌĞΘDĞĚŝĐĂŝĚ^ĞƌǀŝĐĞƐ
ĚĞƚĞƌŵŝŶĞƚŚĂƚƚĞƌŵŝŶĂƚŝŽŶŽƌĂŶLJŽƚŚĞƌƌĞŵĞĚLJŝƐǁĂƌƌĂŶƚĞĚ͕ŝƚǁŝůůƉƌŽǀŝĚĞLJŽƵǁŝƚŚĂƐĞƉĂƌĂƚĞ
ĨŽƌŵĂůŶŽƚŝĨŝĐĂƚŝŽŶŽĨƚŚĂƚĚĞƚĞƌŵŝŶĂƚŝŽŶ͘
dŚŝƐůĞƚƚĞƌƉƌŽǀŝĚĞƐŝŵƉŽƌƚĂŶƚŝŶĨŽƌŵĂƚŝŽŶƌĞŐĂƌĚŝŶŐLJŽƵƌƌĞƐƉŽŶƐĞƚŽƚŚĞƐĞĚĞĨŝĐŝĞŶĐŝĞƐĂŶĚĂĚĚƌĞƐƐĞƐ
ƚŚĞĨŽůůŽǁŝŶŐŝƐƐƵĞƐ͗
KƉƉŽƌƚƵŶŝƚLJƚŽŽƌƌĞĐƚͲƚŚĞĨĂĐŝůŝƚLJŝƐĂůůŽǁĞĚĂŶŽƉƉŽƌƚƵŶŝƚLJƚŽĐŽƌƌĞĐƚŝĚĞŶƚŝĨŝĞĚĚĞĨŝĐŝĞŶĐŝĞƐ
KƉƉŽƌƚƵŶŝƚLJƚŽŽƌƌĞĐƚͲƚŚĞĨĂĐŝůŝƚLJŝƐĂůůŽǁĞĚĂŶŽƉƉŽƌƚƵŶŝƚLJƚŽĐŽƌƌĞĐƚŝĚĞŶƚŝĨŝĞĚĚĞĨŝĐŝĞŶĐŝĞƐ
ďĞĨŽƌĞƌĞŵĞĚŝĞƐĂƌĞŝŵƉŽƐĞĚ͖
WůĂŶŽĨŽƌƌĞĐƚŝŽŶͲǁŚĞŶĂƉůĂŶŽĨĐŽƌƌĞĐƚŝŽŶǁŝůůďĞĚƵĞĂŶĚƚŚĞŝŶĨŽƌŵĂƚŝŽŶƚŽďĞĐŽŶƚĂŝŶĞĚ
WůĂŶŽĨŽƌƌĞĐƚŝŽŶͲǁŚĞŶĂƉůĂŶŽĨĐŽƌƌĞĐƚŝŽŶǁŝůůďĞĚƵĞĂŶĚƚŚĞŝŶĨŽƌŵĂƚŝŽŶƚŽďĞĐŽŶƚĂŝŶĞĚ
ŝŶƚŚĂƚĚŽĐƵŵĞŶƚ͖ ZĞŵĞĚŝĞƐͲƚŚĞƚLJƉĞŽĨƌĞŵĞĚŝĞƐƚŚĂƚǁŝůůďĞŝŵƉŽƐĞĚǁŝƚŚƚŚĞĂƵƚŚŽƌŝnjĂƚŝŽŶŽĨƚŚĞ
ZĞŵĞĚŝĞƐͲƚŚĞƚLJƉĞŽĨƌĞŵĞĚŝĞƐƚŚĂƚǁŝůůďĞŝŵƉŽƐĞĚǁŝƚŚƚŚĞĂƵƚŚŽƌŝnjĂƚŝŽŶŽĨƚŚĞ
ĞŶƚĞƌƐĨŽƌDĞĚŝĐĂƌĞĂŶĚDĞĚŝĐĂŝĚ^ĞƌǀŝĐĞƐ;D^ͿŝĨƐƵďƐƚĂŶƚŝĂůĐŽŵƉůŝĂŶĐĞŝƐŶŽƚĂƚƚĂŝŶĞĚĂƚ
ƚŚĞƚŝŵĞŽĨĂƌĞǀŝƐŝƚ͖
ŶĞƋƵĂůŽƉƉŽƌƚƵŶŝƚLJĞŵƉůŽLJĞƌ
ŽƵŶƚƌLJDĂŶŽƌ,ĞĂůƚŚΘZĞŚĂďƚƌ
DĂƌĐŚϭ͕ϮϬϭϲ
WĂŐĞϮ
WŽƚĞŶƚŝĂůŽŶƐĞƋƵĞŶĐĞƐͲƚŚĞĐŽŶƐĞƋƵĞŶĐĞƐŽĨŶŽƚĂƚƚĂŝŶŝŶŐƐƵďƐƚĂŶƚŝĂůĐŽŵƉůŝĂŶĐĞϯĂŶĚϲ
WŽƚĞŶƚŝĂůŽŶƐĞƋƵĞŶĐĞƐͲƚŚĞĐŽŶƐĞƋƵĞŶĐĞƐŽĨŶŽƚĂƚƚĂŝŶŝŶŐƐƵďƐƚĂŶƚŝĂůĐŽŵƉůŝĂŶĐĞϯĂŶĚϲ
ŵŽŶƚŚƐĂĨƚĞƌƚŚĞƐƵƌǀĞLJĚĂƚĞ͖ĂŶĚ
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/ŶĨŽƌŵĂůŝƐƉƵƚĞZĞƐŽůƵƚŝŽŶͲLJŽƵƌƌŝŐŚƚƚŽƌĞƋƵĞƐƚĂŶŝŶĨŽƌŵĂůƌĞĐŽŶƐŝĚĞƌĂƚŝŽŶƚŽĚŝƐƉƵƚĞƚŚĞ
ĂƚƚĂĐŚĞĚĚĞĨŝĐŝĞŶĐŝĞƐ͘
ĂƚƚĂĐŚĞĚĚĞĨŝĐŝĞŶĐŝĞƐ͘ WůĞĂƐĞŶŽƚĞ͕ŝƚŝƐLJŽƵƌƌĞƐƉŽŶƐŝďŝůŝƚLJƚŽƐŚĂƌĞƚŚĞŝŶĨŽƌŵĂƚŝŽŶĐŽŶƚĂŝŶĞĚŝŶƚŚŝƐůĞƚƚĞƌĂŶĚƚŚĞƌĞƐƵůƚƐŽĨ
ƚŚŝƐǀŝƐŝƚǁŝƚŚƚŚĞWƌĞƐŝĚĞŶƚŽĨLJŽƵƌĨĂĐŝůŝƚLJΖƐ'ŽǀĞƌŶŝŶŐŽĚLJ͘
WZdDEdKEdd
YƵĞƐƚŝŽŶƐƌĞŐĂƌĚŝŶŐƚŚŝƐůĞƚƚĞƌĂŶĚĂůůĚŽĐƵŵĞŶƚƐƐƵďŵŝƚƚĞĚĂƐĂƌĞƐƉŽŶƐĞƚŽƚŚĞƌĞƐŝĚĞŶƚĐĂƌĞ
ĚĞĨŝĐŝĞŶĐŝĞƐ;ƚŚŽƐĞƉƌĞĐĞĚĞĚďLJĂΗ&ΗƚĂŐͿ͕ŝ͘Ğ͕͘ƚŚĞƉůĂŶŽĨĐŽƌƌĞĐƚŝŽŶƐŚŽƵůĚďĞĚŝƌĞĐƚĞĚƚŽ͗
:ĞƐƐŝĐĂ^ĞůůŶĞƌ͕hŶŝƚ^ƵƉĞƌǀŝƐŽƌ
:ĞƐƐŝĐĂ^ĞůůŶĞƌ͕hŶŝƚ^ƵƉĞƌǀŝƐŽƌ
DŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚ
^ƚ͘ůŽƵĚ^ƵƌǀĞLJdĞĂŵ
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ϯϯϯϯtĞƐƚŝǀŝƐŝŽŶ͕ηϮϭϮ ^ƚ͘ůŽƵĚ͕DŝŶŶĞƐŽƚĂϱϲϯϬϭ
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KWWKZdhE/dzdKKZZd
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ďĞĨŽƌĞƌĞŵĞĚŝĞƐǁŝůůďĞŝŵƉŽƐĞĚǁŚĞŶĂĐƚƵĂůŚĂƌŵǁĂƐĐŝƚĞĚĂƚƚŚĞůĂƐƚƐƚĂŶĚĂƌĚŽƌŝŶƚĞƌǀĞŶŝŶŐ
ƐƵƌǀĞLJĂŶĚĂůƐŽĐŝƚĞĚĂƚƚŚĞĐƵƌƌĞŶƚƐƵƌǀĞLJ͘zŽƵƌĨĂĐŝůŝƚLJĚŽĞƐŶŽƚŵĞĞƚƚŚŝƐĐƌŝƚĞƌŝŽŶ͘dŚĞƌĞĨŽƌĞ͕ŝĨ
LJŽƵƌĨĂĐŝůŝƚLJŚĂƐŶŽƚĂĐŚŝĞǀĞĚƐƵďƐƚĂŶƚŝĂůĐŽŵƉůŝĂŶĐĞďLJƉƌŝůϭϬ͕ϮϬϭϲ͕ƚŚĞĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚǁŝůů
ŝŵƉŽƐĞƚŚĞĨŽůůŽǁŝŶŐƌĞŵĞĚLJ͗
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^ƚĂƚĞDŽŶŝƚŽƌŝŶŐ͘;ϰϮ&Zϰϴϴ͘ϰϮϮͿ
W>EK&KZZd/KE;WŽͿ
WŽĨŽƌƚŚĞĚĞĨŝĐŝĞŶĐŝĞƐŵƵƐƚďĞƐƵďŵŝƚƚĞĚǁŝƚŚŝŶƚĞŶĐĂůĞŶĚĂƌĚĂLJƐŽĨLJŽƵƌƌĞĐĞŝƉƚŽĨƚŚŝƐůĞƚƚĞƌ͘
ƚĞŶĐĂůĞŶĚĂƌĚĂLJƐ
ƚĞŶĐĂůĞŶĚĂƌĚĂLJƐ
zŽƵƌWŽŵƵƐƚ͗
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ĚĚƌĞƐƐŚŽǁĐŽƌƌĞĐƚŝǀĞĂĐƚŝŽŶǁŝůůďĞĂĐĐŽŵƉůŝƐŚĞĚĨŽƌƚŚŽƐĞƌĞƐŝĚĞŶƚƐĨŽƵŶĚƚŽŚĂǀĞ
ďĞĞŶĂĨĨĞĐƚĞĚďLJƚŚĞĚĞĨŝĐŝĞŶƚƉƌĂĐƚŝĐĞ͖
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ĚĚƌĞƐƐŚŽǁƚŚĞĨĂĐŝůŝƚLJǁŝůůŝĚĞŶƚŝĨLJŽƚŚĞƌƌĞƐŝĚĞŶƚƐŚĂǀŝŶŐƚŚĞƉŽƚĞŶƚŝĂůƚŽďĞĂĨĨĞĐƚĞĚ
ŽƵŶƚƌLJDĂŶŽƌ,ĞĂůƚŚΘZĞŚĂďƚƌ
DĂƌĐŚϭ͕ϮϬϭϲ
WĂŐĞϯ
ďLJƚŚĞƐĂŵĞĚĞĨŝĐŝĞŶƚƉƌĂĐƚŝĐĞ͖
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ĚĚƌĞƐƐǁŚĂƚŵĞĂƐƵƌĞƐǁŝůůďĞƉƵƚŝŶƚŽƉůĂĐĞŽƌƐLJƐƚĞŵŝĐĐŚĂŶŐĞƐŵĂĚĞƚŽĞŶƐƵƌĞƚŚĂƚ
ƚŚĞĚĞĨŝĐŝĞŶƚƉƌĂĐƚŝĐĞǁŝůůŶŽƚƌĞĐƵƌ͖
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ŝŶĐĂƐĞƐǁŚĞƌĞŶŽƚŝĨŝĐĂƚŝŽŶĂďŽƵƚƚŚĞĂĐĐĞƉƚĂďŝůŝƚLJŽĨƚŚĞŝƌƉůĂŶŽĨĐŽƌƌĞĐƚŝŽŶŝƐ ŶŽƚŵĂĚĞƚŝŵĞůLJ͘dŚĞƉůĂŶŽĨĐŽƌƌĞĐƚŝŽŶǁŝůůƐĞƌǀĞĂƐƚŚĞĨĂĐŝůŝƚLJ͛ƐĂůůĞŐĂƚŝŽŶŽĨ ĐŽŵƉůŝĂŶĐĞ͖ĂŶĚ͕
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dŚĞƐƚĂƚĞĂŐĞŶĐLJŵĂLJ͕ŝŶůŝĞƵŽĨĂƌĞǀŝƐŝƚ͕ĚĞƚĞƌŵŝŶĞĐŽƌƌĞĐƚŝŽŶĂŶĚĐŽŵƉůŝĂŶĐĞďLJĂĐĐĞƉƚŝŶŐƚŚĞ
ĨĂĐŝůŝƚLJΖƐWŽŝĨƚŚĞWŽŝƐƌĞĂƐŽŶĂďůĞ͕ĂĚĚƌĞƐƐĞƐƚŚĞƉƌŽďůĞŵĂŶĚƉƌŽǀŝĚĞƐĞǀŝĚĞŶĐĞƚŚĂƚƚŚĞĐŽƌƌĞĐƚŝǀĞ
ĂĐƚŝŽŶŚĂƐŽĐĐƵƌƌĞĚ͘
/ĨĂŶĂĐĐĞƉƚĂďůĞWŽŝƐŶŽƚƌĞĐĞŝǀĞĚǁŝƚŚŝŶϭϬĐĂůĞŶĚĂƌĚĂLJƐĨƌŽŵƚŚĞƌĞĐĞŝƉƚŽĨƚŚŝƐůĞƚƚĞƌ͕ǁĞǁŝůů
ƌĞĐŽŵŵĞŶĚƚŽƚŚĞD^ZĞŐŝŽŶsKĨĨŝĐĞƚŚĂƚŽŶĞŽƌŵŽƌĞŽĨƚŚĞĨŽůůŽǁŝŶŐƌĞŵĞĚŝĞƐďĞŝŵƉŽƐĞĚ͗
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KƉƚŝŽŶĂůĚĞŶŝĂůŽĨƉĂLJŵĞŶƚĨŽƌŶĞǁDĞĚŝĐĂƌĞĂŶĚDĞĚŝĐĂŝĚĂĚŵŝƐƐŝŽŶƐ;ϰϮ&Z ϰϴϴ͘ϰϭϳ;ĂͿͿ͖
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WĞƌĚĂLJĐŝǀŝůŵŽŶĞLJƉĞŶĂůƚLJ;ϰϮ&Zϰϴϴ͘ϰϯϬƚŚƌŽƵŐŚϰϴϴ͘ϰϰϰͿ͘
&ĂŝůƵƌĞƚŽƐƵďŵŝƚĂŶĂĐĐĞƉƚĂďůĞWŽĐŽƵůĚĂůƐŽƌĞƐƵůƚŝŶƚŚĞƚĞƌŵŝŶĂƚŝŽŶŽĨLJŽƵƌĨĂĐŝůŝƚLJ͛ƐDĞĚŝĐĂƌĞ
ĂŶĚͬŽƌDĞĚŝĐĂŝĚĂŐƌĞĞŵĞŶƚ͘
WZ^hDWd/KEK&KDW>/EͲZ/>>>'d/KEK&KDW>/E
dŚĞĨĂĐŝůŝƚLJΖƐWŽǁŝůůƐĞƌǀĞĂƐLJŽƵƌĂůůĞŐĂƚŝŽŶŽĨĐŽŵƉůŝĂŶĐĞƵƉŽŶƚŚĞĞƉĂƌƚŵĞŶƚΖƐĂĐĐĞƉƚĂŶĐĞ͘zŽƵƌ
ƐŝŐŶĂƚƵƌĞĂƚƚŚĞďŽƚƚŽŵŽĨƚŚĞĨŝƌƐƚƉĂŐĞŽĨƚŚĞD^ͲϮϱϲϳĨŽƌŵǁŝůůďĞƵƐĞĚĂƐǀĞƌŝĨŝĐĂƚŝŽŶŽĨ
ĐŽŵƉůŝĂŶĐĞ͘/ŶŽƌĚĞƌĨŽƌLJŽƵƌĂůůĞŐĂƚŝŽŶŽĨĐŽŵƉůŝĂŶĐĞƚŽďĞĂĐĐĞƉƚĂďůĞƚŽƚŚĞĞƉĂƌƚŵĞŶƚ͕ƚŚĞWŽ
ŵƵƐƚŵĞĞƚƚŚĞĐƌŝƚĞƌŝĂůŝƐƚĞĚŝŶƚŚĞƉůĂŶŽĨĐŽƌƌĞĐƚŝŽŶƐĞĐƚŝŽŶĂďŽǀĞ͘zŽƵǁŝůůďĞŶŽƚŝĨŝĞĚďLJƚŚĞ
DŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚ͕>ŝĐĞŶƐŝŶŐĂŶĚĞƌƚŝĨŝĐĂƚŝŽŶWƌŽŐƌĂŵƐƚĂĨĨĂŶĚͬŽƌƚŚĞĞƉĂƌƚŵĞŶƚŽĨ
WƵďůŝĐ^ĂĨĞƚLJ͕^ƚĂƚĞ&ŝƌĞDĂƌƐŚĂůŝǀŝƐŝŽŶƐƚĂĨĨ͕ŝĨLJŽƵƌWŽĨŽƌƚŚĞƌĞƐƉĞĐƚŝǀĞĚĞĨŝĐŝĞŶĐŝĞƐ;ŝĨĂŶLJͿŝƐ
ŽƵŶƚƌLJDĂŶŽƌ,ĞĂůƚŚΘZĞŚĂďƚƌ
DĂƌĐŚϭ͕ϮϬϭϲ
WĂŐĞϰ
ĂĐĐĞƉƚĂďůĞ͘
sZ/&/d/KEK&^h^dEd/>KDW>/E
hƉŽŶƌĞĐĞŝƉƚŽĨĂŶĂĐĐĞƉƚĂďůĞWŽ͕ĂŶŽŶƐŝƚĞƌĞǀŝƐŝƚŽĨLJŽƵƌĨĂĐŝůŝƚLJŵĂLJďĞĐŽŶĚƵĐƚĞĚƚŽǀĂůŝĚĂƚĞƚŚĂƚ
ƐƵďƐƚĂŶƚŝĂůĐŽŵƉůŝĂŶĐĞǁŝƚŚƚŚĞƌĞŐƵůĂƚŝŽŶƐŚĂƐďĞĞŶĂƚƚĂŝŶĞĚŝŶĂĐĐŽƌĚĂŶĐĞǁŝƚŚLJŽƵƌǀĞƌŝĨŝĐĂƚŝŽŶ͘
WŽƐƚĞƌƚŝĨŝĐĂƚŝŽŶZĞǀŝƐŝƚ;WZͿǁŝůůŽĐĐƵƌĂĨƚĞƌƚŚĞĚĂƚĞLJŽƵŝĚĞŶƚŝĨŝĞĚƚŚĂƚĐŽŵƉůŝĂŶĐĞǁĂƐĂĐŚŝĞǀĞĚŝŶ
LJŽƵƌƉůĂŶŽĨĐŽƌƌĞĐƚŝŽŶ͘
/ĨƐƵďƐƚĂŶƚŝĂůĐŽŵƉůŝĂŶĐĞŚĂƐďĞĞŶĂĐŚŝĞǀĞĚ͕ĐĞƌƚŝĨŝĐĂƚŝŽŶŽĨLJŽƵƌĨĂĐŝůŝƚLJŝŶƚŚĞDĞĚŝĐĂƌĞĂŶĚͬŽƌ DĞĚŝĐĂŝĚƉƌŽŐƌĂŵ;ƐͿǁŝůůďĞĐŽŶƚŝŶƵĞĚĂŶĚƌĞŵĞĚŝĞƐǁŝůůŶŽƚďĞŝŵƉŽƐĞĚ͘ŽŵƉůŝĂŶĐĞŝƐĐĞƌƚŝĨŝĞĚĂƐŽĨ
ƚŚĞůĂƚĞƐƚĐŽƌƌĞĐƚŝŽŶĚĂƚĞŽŶƚŚĞĂƉƉƌŽǀĞĚWŽ͕ƵŶůĞƐƐŝƚŝƐĚĞƚĞƌŵŝŶĞĚƚŚĂƚĞŝƚŚĞƌĐŽƌƌĞĐƚŝŽŶĂĐƚƵĂůůLJ
ŽĐĐƵƌƌĞĚďĞƚǁĞĞŶƚŚĞůĂƚĞƐƚĐŽƌƌĞĐƚŝŽŶĚĂƚĞŽŶƚŚĞWŽĂŶĚƚŚĞĚĂƚĞŽĨƚŚĞĨŝƌƐƚƌĞǀŝƐŝƚ͕ŽƌĐŽƌƌĞĐƚŝŽŶ
ŽĐĐƵƌƌĞĚƐŽŽŶĞƌƚŚĂŶƚŚĞůĂƚĞƐƚĐŽƌƌĞĐƚŝŽŶĚĂƚĞŽŶƚŚĞWŽ͘
KƌŝŐŝŶĂůĚĞĨŝĐŝĞŶĐŝĞƐŶŽƚĐŽƌƌĞĐƚĞĚ
/ĨLJŽƵƌĨĂĐŝůŝƚLJŚĂƐŶŽƚĂĐŚŝĞǀĞĚƐƵďƐƚĂŶƚŝĂůĐŽŵƉůŝĂŶĐĞ͕ǁĞǁŝůůŝŵƉŽƐĞƚŚĞƌĞŵĞĚŝĞƐĚĞƐĐƌŝďĞĚĂďŽǀĞ͘
/ĨƚŚĞůĞǀĞůŽĨŶŽŶĐŽŵƉůŝĂŶĐĞǁŽƌƐĞŶĞĚƚŽĂƉŽŝŶƚǁŚĞƌĞĂŚŝŐŚĞƌĐĂƚĞŐŽƌLJŽĨƌĞŵĞĚLJŵĂLJďĞŝŵƉŽƐĞĚ͕
ǁĞǁŝůůƌĞĐŽŵŵĞŶĚƚŽƚŚĞD^ZĞŐŝŽŶsKĨĨŝĐĞƚŚĂƚƚŚŽƐĞŽƚŚĞƌƌĞŵĞĚŝĞƐďĞŝŵƉŽƐĞĚ͘
KƌŝŐŝŶĂůĚĞĨŝĐŝĞŶĐŝĞƐŶŽƚĐŽƌƌĞĐƚĞĚĂŶĚŶĞǁĚĞĨŝĐŝĞŶĐŝĞƐĨŽƵŶĚĚƵƌŝŶŐƚŚĞƌĞǀŝƐŝƚ
/ĨŶĞǁĚĞĨŝĐŝĞŶĐŝĞƐĂƌĞŝĚĞŶƚŝĨŝĞĚĂƚƚŚĞƚŝŵĞŽĨƚŚĞƌĞǀŝƐŝƚ͕ƚŚŽƐĞĚĞĨŝĐŝĞŶĐŝĞƐŵĂLJďĞĚŝƐƉƵƚĞĚƚŚƌŽƵŐŚ
ƚŚĞŝŶĨŽƌŵĂůĚŝƐƉƵƚĞƌĞƐŽůƵƚŝŽŶƉƌŽĐĞƐƐ͘,ŽǁĞǀĞƌ͕ƚŚĞƌĞŵĞĚŝĞƐƐƉĞĐŝĨŝĞĚŝŶƚŚŝƐůĞƚƚĞƌǁŝůůďĞŝŵƉŽƐĞĚ
ĨŽƌŽƌŝŐŝŶĂůĚĞĨŝĐŝĞŶĐŝĞƐŶŽƚĐŽƌƌĞĐƚĞĚ͘/ĨƚŚĞĚĞĨŝĐŝĞŶĐŝĞƐŝĚĞŶƚŝĨŝĞĚĂƚƚŚĞƌĞǀŝƐŝƚƌĞƋƵŝƌĞƚŚĞŝŵƉŽƐŝƚŝŽŶ ŽĨĂŚŝŐŚĞƌĐĂƚĞŐŽƌLJŽĨƌĞŵĞĚLJ͕ǁĞǁŝůůƌĞĐŽŵŵĞŶĚƚŽƚŚĞD^ZĞŐŝŽŶsKĨĨŝĐĞƚŚĂƚƚŚŽƐĞƌĞŵĞĚŝĞƐďĞ
ŝŵƉŽƐĞĚ͘
KƌŝŐŝŶĂůĚĞĨŝĐŝĞŶĐŝĞƐĐŽƌƌĞĐƚĞĚďƵƚŶĞǁĚĞĨŝĐŝĞŶĐŝĞƐĨŽƵŶĚĚƵƌŝŶŐƚŚĞƌĞǀŝƐŝƚ
/ĨŶĞǁĚĞĨŝĐŝĞŶĐŝĞƐĂƌĞĨŽƵŶĚĂƚƚŚĞƌĞǀŝƐŝƚ͕ƚŚĞƌĞŵĞĚŝĞƐƐƉĞĐŝĨŝĞĚŝŶƚŚŝƐůĞƚƚĞƌǁŝůůďĞŝŵƉŽƐĞĚ͘/ĨƚŚĞ
ĚĞĨŝĐŝĞŶĐŝĞƐŝĚĞŶƚŝĨŝĞĚĂƚƚŚĞƌĞǀŝƐŝƚƌĞƋƵŝƌĞƚŚĞŝŵƉŽƐŝƚŝŽŶŽĨĂŚŝŐŚĞƌĐĂƚĞŐŽƌLJŽĨƌĞŵĞĚLJ͕ǁĞǁŝůů
ƌĞĐŽŵŵĞŶĚƚŽƚŚĞD^ZĞŐŝŽŶsKĨĨŝĐĞƚŚĂƚƚŚŽƐĞƌĞŵĞĚŝĞƐďĞŝŵƉŽƐĞĚ͘zŽƵǁŝůůďĞƉƌŽǀŝĚĞĚƚŚĞ
ƌĞƋƵŝƌĞĚŶŽƚŝĐĞďĞĨŽƌĞƚŚĞŝŵƉŽƐŝƚŝŽŶŽĨĂŶĞǁƌĞŵĞĚLJŽƌŝŶĨŽƌŵĞĚŝĨĂŶŽƚŚĞƌĚĂƚĞǁŝůůďĞƐĞƚĨŽƌƚŚĞ
ŝŵƉŽƐŝƚŝŽŶŽĨƚŚĞƐĞƌĞŵĞĚŝĞƐ͘
&/>hZdK,/s^h^dEd/>KDW>/Ezd,d,/ZKZ^/yd,DKEd,&dZd,>^d
zK&d,^hZsz
/ĨƐƵďƐƚĂŶƚŝĂůĐŽŵƉůŝĂŶĐĞǁŝƚŚƚŚĞƌĞŐƵůĂƚŝŽŶƐŝƐŶŽƚǀĞƌŝĨŝĞĚďLJDĂLJϮϰ͕ϮϬϭϲ;ƚŚƌĞĞŵŽŶƚŚƐĂĨƚĞƌƚŚĞ
ŝĚĞŶƚŝĨŝĐĂƚŝŽŶŽĨŶŽŶĐŽŵƉůŝĂŶĐĞͿ͕ƚŚĞD^ZĞŐŝŽŶsKĨĨŝĐĞŵƵƐƚĚĞŶLJƉĂLJŵĞŶƚĨŽƌŶĞǁĂĚŵŝƐƐŝŽŶƐĂƐ
ŵĂŶĚĂƚĞĚďLJƚŚĞ^ŽĐŝĂů^ĞĐƵƌŝƚLJĐƚ;ƚŚĞĐƚͿĂƚ^ĞĐƚŝŽŶƐϭϴϭϵ;ŚͿ;ϮͿ;ͿĂŶĚϭϵϭϵ;ŚͿ;ϮͿ;ͿĂŶĚ&ĞĚĞƌĂů
ƌĞŐƵůĂƚŝŽŶƐĂƚϰϮ&Z^ĞĐƚŝŽŶϰϴϴ͘ϰϭϳ;ďͿ͘dŚŝƐŵĂŶĚĂƚŽƌLJĚĞŶŝĂůŽĨƉĂLJŵĞŶƚƐǁŝůůďĞďĂƐĞĚŽŶƚŚĞ
ŽƵŶƚƌLJDĂŶŽƌ,ĞĂůƚŚΘZĞŚĂďƚƌ
DĂƌĐŚϭ͕ϮϬϭϲ
WĂŐĞϱ
ĨĂŝůƵƌĞƚŽĐŽŵƉůLJǁŝƚŚĚĞĨŝĐŝĞŶĐŝĞƐŽƌŝŐŝŶĂůůLJĐŽŶƚĂŝŶĞĚŝŶƚŚĞ^ƚĂƚĞŵĞŶƚŽĨĞĨŝĐŝĞŶĐŝĞƐ͕ƵƉŽŶƚŚĞ
ŝĚĞŶƚŝĨŝĐĂƚŝŽŶŽĨŶĞǁĚĞĨŝĐŝĞŶĐŝĞƐĂƚƚŚĞƚŝŵĞŽĨƚŚĞƌĞǀŝƐŝƚ͕ŽƌŝĨĚĞĨŝĐŝĞŶĐŝĞƐŚĂǀĞďĞĞŶŝƐƐƵĞĚĂƐƚŚĞ
ƌĞƐƵůƚŽĨĂĐŽŵƉůĂŝŶƚǀŝƐŝƚŽƌŽƚŚĞƌƐƵƌǀĞLJĐŽŶĚƵĐƚĞĚĂĨƚĞƌƚŚĞŽƌŝŐŝŶĂůƐƚĂƚĞŵĞŶƚŽĨĚĞĨŝĐŝĞŶĐŝĞƐǁĂƐ
ŝƐƐƵĞĚ͘dŚŝƐŵĂŶĚĂƚŽƌLJĚĞŶŝĂůŽĨƉĂLJŵĞŶƚŝƐŝŶĂĚĚŝƚŝŽŶƚŽĂŶLJƌĞŵĞĚŝĞƐƚŚĂƚŵĂLJƐƚŝůůďĞŝŶĞĨĨĞĐƚĂƐŽĨ
ƚŚŝƐĚĂƚĞ͘
tĞǁŝůůĂůƐŽƌĞĐŽŵŵĞŶĚƚŽƚŚĞD^ZĞŐŝŽŶsKĨĨŝĐĞĂŶĚͬŽƌƚŚĞDŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ƵŵĂŶ
^ĞƌǀŝĐĞƐƚŚĂƚLJŽƵƌƉƌŽǀŝĚĞƌĂŐƌĞĞŵĞŶƚďĞƚĞƌŵŝŶĂƚĞĚďLJƵŐƵƐƚϮϰ͕ϮϬϭϲ;ƐŝdžŵŽŶƚŚƐĂĨƚĞƌƚŚĞ
ŝĚĞŶƚŝĨŝĐĂƚŝŽŶŽĨŶŽŶĐŽŵƉůŝĂŶĐĞͿŝĨLJŽƵƌĨĂĐŝůŝƚLJĚŽĞƐŶŽƚĂĐŚŝĞǀĞƐƵďƐƚĂŶƚŝĂůĐŽŵƉůŝĂŶĐĞ͘dŚŝƐĂĐƚŝŽŶŝƐ
ŵĂŶĚĂƚĞĚďLJƚŚĞ^ŽĐŝĂů^ĞĐƵƌŝƚLJĐƚĂƚ^ĞĐƚŝŽŶƐϭϴϭϵ;ŚͿ;ϮͿ;ͿĂŶĚϭϵϭϵ;ŚͿ;ϯͿ;ͿĂŶĚ&ĞĚĞƌĂů
ƌĞŐƵůĂƚŝŽŶƐĂƚϰϮ&Z^ĞĐƚŝŽŶƐϰϴϴ͘ϰϭϮĂŶĚϰϴϴ͘ϰϱϲ͘
/E&KZD>/^WhdZ^K>hd/KE
/ŶĂĐĐŽƌĚĂŶĐĞǁŝƚŚϰϮ&Zϰϴϴ͘ϯϯϭ͕LJŽƵŚĂǀĞŽŶĞŽƉƉŽƌƚƵŶŝƚLJƚŽƋƵĞƐƚŝŽŶĐŝƚĞĚĚĞĨŝĐŝĞŶĐŝĞƐƚŚƌŽƵŐŚ
ĂŶŝŶĨŽƌŵĂůĚŝƐƉƵƚĞƌĞƐŽůƵƚŝŽŶƉƌŽĐĞƐƐ͘zŽƵĂƌĞƌĞƋƵŝƌĞĚƚŽƐĞŶĚLJŽƵƌǁƌŝƚƚĞŶƌĞƋƵĞƐƚ͕ĂůŽŶŐǁŝƚŚƚŚĞ
ƐƉĞĐŝĨŝĐĚĞĨŝĐŝĞŶĐŝĞƐďĞŝŶŐĚŝƐƉƵƚĞĚ͕ĂŶĚĂŶĞdžƉůĂŶĂƚŝŽŶŽĨǁŚLJLJŽƵĂƌĞĚŝƐƉƵƚŝŶŐƚŚŽƐĞĚĞĨŝĐŝĞŶĐŝĞƐ͕ƚŽ͗
EƵƌƐŝŶŐ,ŽŵĞ/ŶĨŽƌŵĂůŝƐƉƵƚĞWƌŽĐĞƐƐ
EƵƌƐŝŶŐ,ŽŵĞ/ŶĨŽƌŵĂůŝƐƉƵƚĞWƌŽĐĞƐƐ
DŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚ
ŝǀŝƐŝŽŶŽĨŽŵƉůŝĂŶĐĞDŽŶŝƚŽƌŝŶŐ
W͘K͘ŽdžϲϰϵϬϬ
^ƚ͘WĂƵů͕DŝŶŶĞƐŽƚĂϱϱϭϲϰͲϬϵϬϬ
dŚŝƐƌĞƋƵĞƐƚŵƵƐƚďĞƐĞŶƚǁŝƚŚŝŶƚŚĞƐĂŵĞƚĞŶĚĂLJƐLJŽƵŚĂǀĞĨŽƌƐƵďŵŝƚƚŝŶŐĂWŽĨŽƌƚŚĞĐŝƚĞĚ
ĚĞĨŝĐŝĞŶĐŝĞƐ͘ůůƌĞƋƵĞƐƚƐĨŽƌĂŶ/ZŽƌ//ZŽĨĨĞĚĞƌĂůĚĞĨŝĐŝĞŶĐŝĞƐŵƵƐƚďĞƐƵďŵŝƚƚĞĚǀŝĂƚŚĞǁĞďĂƚ͗
ŚƚƚƉ͗ͬͬǁǁǁ͘ŚĞĂůƚŚ͘ƐƚĂƚĞ͘ŵŶ͘ƵƐͬĚŝǀƐͬĨƉĐͬƉƌŽĨŝŶĨŽͬůƚĐͬůƚĐͺŝĚƌ͘ĐĨŵ zŽƵŵƵƐƚŶŽƚŝĨLJD,ĂƚƚŚŝƐǁĞďƐŝƚĞŽĨLJŽƵƌƌĞƋƵĞƐƚĨŽƌĂŶ/ZŽƌ//ZǁŝƚŚŝŶƚŚĞϭϬĐĂůĞŶĚĂƌĚĂLJ
ƉĞƌŝŽĚĂůůŽƚƚĞĚĨŽƌƐƵďŵŝƚƚŝŶŐĂŶĂĐĐĞƉƚĂďůĞƉůĂŶŽĨĐŽƌƌĞĐƚŝŽŶ͘ĐŽƉLJŽĨƚŚĞĞƉĂƌƚŵĞŶƚ͛ƐŝŶĨŽƌŵĂů
ĚŝƐƉƵƚĞƌĞƐŽůƵƚŝŽŶƉŽůŝĐŝĞƐĂƌĞƉŽƐƚĞĚŽŶƚŚĞD,/ŶĨŽƌŵĂƚŝŽŶƵůůĞƚŝŶǁĞďƐŝƚĞĂƚ͗
ŚƚƚƉ͗ͬͬǁǁǁ͘ŚĞĂůƚŚ͘ƐƚĂƚĞ͘ŵŶ͘ƵƐͬĚŝǀƐͬĨƉĐͬƉƌŽĨŝŶĨŽͬŝŶĨŽďƵů͘Śƚŵ
WůĞĂƐĞŶŽƚĞƚŚĂƚƚŚĞĨĂŝůƵƌĞƚŽĐŽŵƉůĞƚĞƚŚĞŝŶĨŽƌŵĂůĚŝƐƉƵƚĞƌĞƐŽůƵƚŝŽŶƉƌŽĐĞƐƐǁŝůůŶŽƚĚĞůĂLJƚŚĞ
ĚĂƚĞƐƐƉĞĐŝĨŝĞĚĨŽƌĐŽŵƉůŝĂŶĐĞŽƌƚŚĞŝŵƉŽƐŝƚŝŽŶŽĨƌĞŵĞĚŝĞƐ͘ YƵĞƐƚŝŽŶƐƌĞŐĂƌĚŝŶŐĂůůĚŽĐƵŵĞŶƚƐƐƵďŵŝƚƚĞĚĂƐĂƌĞƐƉŽŶƐĞƚŽƚŚĞ>ŝĨĞ^ĂĨĞƚLJŽĚĞĚĞĨŝĐŝĞŶĐŝĞƐ;ƚŚŽƐĞ
ƉƌĞĐĞĚĞĚďLJĂΗ<ΗƚĂŐͿ͕ŝ͘Ğ͕͘ƚŚĞƉůĂŶŽĨĐŽƌƌĞĐƚŝŽŶ͕ƌĞƋƵĞƐƚĨŽƌǁĂŝǀĞƌƐ͕ƐŚŽƵůĚďĞĚŝƌĞĐƚĞĚƚŽ͗
Dƌ͘dŽŵ>ŝŶŚŽĨĨ͕/ŶƚĞƌŝŵ^ƵƉĞƌǀŝƐŽƌ
,ĞĂůƚŚĂƌĞ&ŝƌĞ/ŶƐƉĞĐƚŝŽŶƐ
^ƚĂƚĞ&ŝƌĞDĂƌƐŚĂůŝǀŝƐŝŽŶ
ϰϰϰDŝŶŶĞƐŽƚĂ^ƚƌĞĞƚ͕^ƵŝƚĞϭϰϱ
^ƚ͘WĂƵů͕DŝŶŶĞƐŽƚĂϱϱϭϬϭͲϱϭϰϱ
ŽƵŶƚƌLJDĂŶŽƌ,ĞĂůƚŚΘZĞŚĂďƚƌ
DĂƌĐŚϭ͕ϮϬϭϲ
WĂŐĞϲ
ŵĂŝů͗ƚŽŵ͘ůŝŶŚŽĨĨΛƐƚĂƚĞ͘ŵŶ͘ƵƐ
ƚŽŵ͘ůŝŶŚŽĨĨΛƐƚĂƚĞ͘ŵŶ͘ƵƐ ƚŽŵ͘ůŝŶŚŽĨĨΛƐƚĂƚĞ͘ŵŶ͘ƵƐ
dĞůĞƉŚŽŶĞ͗;ϲϱϭͿϮϬϭͲϳϮϬϱ
&Ădž͗;ϲϱϭͿϮϭϱͲϬϱϮϱ
&ĞĞůĨƌĞĞƚŽĐŽŶƚĂĐƚŵĞŝĨLJŽƵŚĂǀĞƋƵĞƐƚŝŽŶƐ͘
^ŝŶĐĞƌĞůLJ͕
<ĂƚĞ:ŽŚŶƐdŽŶ͕WƌŽŐƌĂŵ^ƉĞĐŝĂůŝƐƚ
WƌŽŐƌĂŵƐƐƵƌĂŶĐĞhŶŝƚ
>ŝĐĞŶƐŝŶŐĂŶĚĞƌƚŝĨŝĐĂƚŝŽŶWƌŽŐƌĂŵ
,ĞĂůƚŚZĞŐƵůĂƚŝŽŶŝǀŝƐŝŽŶ ϴϱĂƐƚ^ĞǀĞŶƚŚWůĂĐĞ͕^ƵŝƚĞϮϮϬ
W͘K͘ŽdžϲϰϵϬϬ
^ƚ͘WĂƵů͕DŝŶŶĞƐŽƚĂϱϱϭϲϰͲϬϵϬϬ
ŬĂƚĞ͘ũŽŚŶƐƚŽŶΛƐƚĂƚĞ͘ŵŶ͘ƵƐ
dĞůĞƉŚŽŶĞ͗;ϲϱϭͿϮϬϭͲϯϵϵϮ&Ădž͗;ϲϱϭͿϮϭϱͲϵϲϵϳ
ŶĐůŽƐƵƌĞ
ĐĐ͗>ŝĐĞŶƐŝŶŐĂŶĚĞƌƚŝĨŝĐĂƚŝŽŶ&ŝůĞ WZKdd/E'͕D/Ed/E/E'E/DWZKs/E'd,,>d,K&>>D/EE^KdE^
ĞƌƚŝĨŝĞĚDĂŝůηϳϬϭϭϬϰϳϬϬϬϬϬϱϮϲϮϮϳϲϮ
DĂƌĐŚϭ͕ϮϬϭϲ
Dƌ͘ƌŝĂŶ<Ğůŵ͕ĚŵŝŶŝƐƚƌĂƚŽƌ
ŽƵŶƚƌLJDĂŶŽƌ,ĞĂůƚŚΘZĞŚĂďŝůŝƚĂƚŝŽŶĞŶƚĞƌ
ϱϮϬ&ŝƌƐƚ^ƚƌĞĞƚEŽƌƚŚĞĂƐƚ
^ĂƌƚĞůů͕DŝŶŶĞƐŽƚĂϱϲϯϳϳ
ZĞ͗ŶĐůŽƐĞĚ^ƚĂƚĞEƵƌƐŝŶŐ,ŽŵĞ>ŝĐĞŶƐŝŶŐKƌĚĞƌƐͲWƌŽũĞĐƚEƵŵďĞƌ^ϱϯϯϬϬϮϲ
ĞĂƌDƌ͘<Ğůŵ͗
dŚĞĂďŽǀĞĨĂĐŝůŝƚLJǁĂƐƐƵƌǀĞLJĞĚŽŶ&ĞďƌƵĂƌLJϮϭ͕ϮϬϭϲƚŚƌŽƵŐŚ&ĞďƌƵĂƌLJϮϰ͕ϮϬϭϲĨŽƌƚŚĞƉƵƌƉŽƐĞŽĨ
ĂƐƐĞƐƐŝŶŐĐŽŵƉůŝĂŶĐĞǁŝƚŚDŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚEƵƌƐŝŶŐ,ŽŵĞZƵůĞƐĂŶĚƚŽŝŶǀĞƐƚŝŐĂƚĞ
ĐŽŵƉůĂŝŶƚŶƵŵďĞƌ,ϱϯϯϬϬϮϮƚŚĂƚǁĂƐĨŽƵŶĚƚŽďĞƵŶƐƵďƐƚĂŶƚŝĂƚĞĚ͘ƚƚŚĞƚŝŵĞŽĨƚŚĞƐƵƌǀĞLJ͕ƚŚĞ
ƐƵƌǀĞLJƚĞĂŵĨƌŽŵƚŚĞDŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚ͕,ĞĂůƚŚZĞŐƵůĂƚŝŽŶŝǀŝƐŝŽŶ͕ŶŽƚĞĚŽŶĞŽƌŵŽƌĞ
ǀŝŽůĂƚŝŽŶƐŽĨƚŚĞƐĞƌƵůĞƐƚŚĂƚĂƌĞŝƐƐƵĞĚŝŶĂĐĐŽƌĚĂŶĐĞǁŝƚŚDŝŶŶĞƐŽƚĂ^ƚĂƚ͘ƐĞĐƚŝŽŶϭϰϰ͘ϲϱϯĂŶĚͬŽƌ
DŝŶŶĞƐŽƚĂ^ƚĂƚ͘^ĞĐƚŝŽŶϭϰϰ͘ϭϬ͘/Ĩ͕ƵƉŽŶƌĞŝŶƐƉĞĐƚŝŽŶ͕ŝƚŝƐĨŽƵŶĚƚŚĂƚƚŚĞĚĞĨŝĐŝĞŶĐLJŽƌĚĞĨŝĐŝĞŶĐŝĞƐ
ĐŝƚĞĚŚĞƌĞŝŶĂƌĞŶŽƚĐŽƌƌĞĐƚĞĚ͕ĂĐŝǀŝůĨŝŶĞĨŽƌĞĂĐŚĚĞĨŝĐŝĞŶĐLJŶŽƚĐŽƌƌĞĐƚĞĚƐŚĂůůďĞĂƐƐĞƐƐĞĚŝŶ
ĂĐĐŽƌĚĂŶĐĞǁŝƚŚĂƐĐŚĞĚƵůĞŽĨĨŝŶĞƐƉƌŽŵƵůŐĂƚĞĚďLJƌƵůĞŽĨƚŚĞDŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚ͘
dŽĂƐƐŝƐƚŝŶĐŽŵƉůLJŝŶŐǁŝƚŚƚŚĞĐŽƌƌĞĐƚŝŽŶŽƌĚĞƌ;ƐͿ͕Ă͞ƐƵŐŐĞƐƚĞĚŵĞƚŚŽĚŽĨĐŽƌƌĞĐƚŝŽŶ͟ŚĂƐďĞĞŶ
ĂĚĚĞĚ͘dŚŝƐƉƌŽǀŝƐŝŽŶŝƐďĞŝŶŐƐƵŐŐĞƐƚĞĚĂƐŽŶĞŵĞƚŚŽĚƚŚĂƚLJŽƵĐĂŶĨŽůůŽǁƚŽĐŽƌƌĞĐƚƚŚĞĐŝƚĞĚ
ĚĞĨŝĐŝĞŶĐLJ͘WůĞĂƐĞƌĞŵĞŵďĞƌƚŚĂƚƚŚŝƐƉƌŽǀŝƐŝŽŶŝƐŽ
ŶůLJĂƐƵŐŐĞƐƚŝŽŶĂŶĚLJŽƵĂƌĞŶŽƚƌĞƋƵŝƌĞĚƚŽĨŽůůŽǁ
ŝƚ͘&ĂŝůƵƌĞƚŽĨŽůůŽǁƚŚĞƐƵŐŐĞƐƚĞĚŵĞƚŚŽĚǁŝůůŶŽƚƌĞƐƵůƚŝŶƚŚĞŝƐƐƵĂŶĐĞŽĨĂƉĞŶĂůƚLJĂƐƐĞƐƐŵĞŶƚ͘zŽƵ
ĂƌĞƌĞŵŝŶĚĞĚ͕ŚŽǁĞǀĞƌ͕ƚŚĂƚƌĞŐĂƌĚůĞƐƐŽĨƚŚĞŵĞƚŚŽĚƵƐĞĚ͕ĐŽƌƌĞĐƚŝŽŶŽĨƚŚĞĚĞĨŝĐŝĞŶĐLJǁŝƚŚŝŶƚŚĞ
ĞƐƚĂďůŝƐŚĞĚƚŝŵĞĨƌĂŵĞŝƐƌĞƋƵŝƌĞĚ͘dŚĞ͞ƐƵŐŐĞƐƚĞĚŵĞƚŚŽĚŽĨĐŽƌƌĞĐƚŝŽŶ͟ŝƐĨŽƌLJŽƵƌŝŶĨŽƌŵĂƚŝŽŶĂŶĚ
ĂƐƐŝƐƚĂŶĐĞŽŶůLJ͘
dŚĞ^ƚĂƚĞůŝĐĞŶƐŝŶŐŽƌĚĞƌƐĂƌĞĚĞůŝŶĞĂƚĞĚŽŶƚŚĞĂƚƚĂĐŚĞĚDŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚŽƌĚĞƌĨŽƌŵ
;ĂƚƚĂĐŚĞĚͿ͘dŚĞDŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚŝƐĚŽĐƵŵĞŶƚŝŶŐƚŚĞ^ƚĂƚĞ>ŝĐĞŶƐŝŶŐŽƌƌĞĐƚŝŽŶ
KƌĚĞƌƐƵƐŝŶŐĨĞĚĞƌĂůƐŽĨƚǁĂƌĞ͘dĂŐŶƵŵďĞƌƐŚĂǀĞďĞĞŶĂƐƐŝŐŶĞĚƚŽDŝŶŶĞƐŽƚĂƐƚĂƚĞƐƚĂƚƵƚĞƐͬƌƵůĞƐĨŽƌ
EƵƌƐŝŶŐ,ŽŵĞƐ͘
dŚĞĂƐƐŝŐŶĞĚƚĂŐŶƵŵďĞƌĂƉƉĞĂƌƐŝŶƚŚĞĨĂƌůĞĨƚĐŽůƵŵŶĞŶƚŝƚůĞĚΗ/WƌĞĨŝdždĂŐ͘ΗdŚĞƐƚĂƚĞƐƚĂƚƵƚĞͬƌƵůĞ
ŶƵŵďĞƌĂŶĚƚŚĞĐŽƌƌĞƐƉŽŶĚŝŶŐƚĞdžƚŽĨƚŚĞƐƚĂƚĞƐƚĂƚƵƚĞͬƌƵůĞŽƵƚŽĨĐŽŵƉůŝĂŶĐĞŝƐůŝƐƚĞĚŝŶƚŚĞ
Η^ƵŵŵĂƌLJ^ƚĂƚĞŵĞŶƚŽĨĞĨŝĐŝĞŶĐŝĞƐΗĐŽůƵŵŶĂŶĚƌĞƉůĂĐĞƐƚŚĞΗdŽŽŵƉůLJΗƉŽƌƚŝŽŶŽĨƚŚĞĐŽƌƌĞĐƚŝŽŶ
ŽƌĚĞƌ͘dŚŝƐĐŽůƵŵŶĂůƐŽŝŶĐůƵĚĞƐƚŚĞĨŝŶĚŝŶŐƐƚŚĂƚĂƌĞŝŶǀŝŽůĂƚŝŽŶŽĨƚŚĞƐƚĂƚĞƐƚĂƚƵƚĞĂĨƚĞƌƚŚĞ
ƐƚĂƚĞŵĞŶƚ͕ΗdŚŝƐZƵůĞŝƐŶŽƚŵĞƚĂƐĞǀŝĚĞŶĐĞĚďLJ͘Η&ŽůůŽǁŝŶŐƚŚĞƐƵƌǀĞLJŽƌƐĨŝŶĚŝŶŐƐĂƌĞƚŚĞ^ƵŐŐĞƐƚĞĚ
DĞƚŚŽĚŽĨŽƌƌĞĐƚŝŽŶĂŶĚƚŚĞdŝŵĞWĞƌŝŽĚ&ŽƌŽƌƌĞĐƚŝŽŶ͘
ŶĞƋƵĂůŽƉƉŽƌƚƵŶŝƚLJĞŵƉůŽLJĞƌ
ŽƵŶƚƌLJDĂŶŽƌ,ĞĂůƚŚΘZĞŚĂďƚƌ
DĂƌĐŚϭ͕ϮϬϭϲ
WĂŐĞϮ
W>^/^Z'Zd,,/E'K&d,&KhZd,K>hDEt,/,^dd^͕
ΗWZKs/ZΖ^W>EK&KZZd/KE͘Ηd,/^WW>/^dK&Z>&//E/^
KE>z͘d,/^t/>>WWZKE,W'͘ d,Z/^EKZYh/ZDEddK^hD/dW>EK&KZZd/KE&KZs/K>d/KE^K&D/EE^Kd
^dd^ddhd^ͬZh>^͘
tŚĞŶĂůůŽƌĚĞƌƐĂƌĞĐŽƌƌĞĐƚĞĚ͕ƚŚĞŽƌĚĞƌĨŽƌŵƐŚŽƵůĚďĞƐŝŐŶĞĚĂŶĚƌĞƚƵƌŶĞĚƚŽƚŚŝƐŽĨĨŝĐĞĂƚ
DŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚ͕ϯϯϯϯtĞƐƚŝǀŝƐŝŽŶηϮϭϮ͕^ƚůŽƵĚDE͕ϱϲϯϬϭ͘tĞƵƌŐĞLJŽƵƚŽ
ƌĞǀŝĞǁƚŚĞƐĞŽƌĚĞƌƐĐĂƌĞĨƵůůLJ͕ŝƚĞŵďLJŝƚĞŵ͕ĂŶĚŝĨLJŽƵĨŝŶĚƚŚĂƚĂŶLJŽĨƚŚĞŽƌĚĞƌƐĂƌĞŶŽƚŝŶĂĐĐŽƌĚĂŶĐĞ
ǁŝƚŚLJŽƵƌƵŶĚĞƌƐƚĂŶĚŝŶŐĂƚƚŚĞƚŝŵĞŽĨƚŚĞĞdžŝƚĐŽŶĨĞƌĞŶĐĞĨŽůůŽǁŝŶŐƚŚĞƐƵƌǀĞLJ͕LJŽƵƐŚŽƵůĚ
ŝŵŵĞĚŝĂƚĞůLJĐŽŶƚĂĐƚŵĞ͘ zŽƵŵĂLJƌĞƋƵĞƐƚĂŚĞĂƌŝŶŐŽŶĂŶLJĂƐƐĞƐƐŵĞŶƚƐƚŚĂƚŵĂLJƌĞƐƵůƚĨƌŽŵŶŽŶͲĐŽŵƉůŝĂŶĐĞǁŝƚŚƚŚĞƐĞŽƌĚĞƌƐ
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PRINTED: 03/01/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
COUNTRY MANOR HEALTH & REHAB CTR
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
B. WING _____________________________
00627
NAME OF PROVIDER OR SUPPLIER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
02/24/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
520 FIRST STREET NORTHEAST
SARTELL, MN 56377
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
2 000 Initial Comments
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETE
DATE
2 000
*****ATTENTION******
NH LICENSING CORRECTION ORDER
In accordance with Minnesota Statute, section
144A.10, this correction order has been issued
pursuant to a survey. If, upon reinspection, it is
found that the deficiency or deficiencies cited
herein are not corrected, a fine for each violation
not corrected shall be assessed in accordance
with a schedule of fines promulgated by rule of
the Minnesota Department of Health.
Determination of whether a violation has been
corrected requires compliance with all
requirements of the rule provided at the tag
number and MN Rule number indicated below.
When a rule contains several items, failure to
comply with any of the items will be considered
lack of compliance. Lack of compliance upon
re-inspection with any item of multi-part rule will
result in the assessment of a fine even if the item
that was violated during the initial inspection was
corrected.
You may request a hearing on any assessments
that may result from non-compliance with these
orders provided that a written request is made to
the Department within 15 days of receipt of a
notice of assessment for non-compliance.
INITIAL COMMENTS:
On February 21st, 22nd, 23rd, and 24th, 2016,
surveyors of this Department's staff, visited the
above provider and the following correction
orders are issued. When corrections are
completed, please sign and date, make a copy of
these orders and return the original to the
Minnesota Department of Health, Division of
Minnesota Department of Health
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
STATE FORM
TITLE
6899
C4RT11
(X6) DATE
If continuation sheet 1 of 4
PRINTED: 03/01/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
COUNTRY MANOR HEALTH & REHAB CTR
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
B. WING _____________________________
00627
NAME OF PROVIDER OR SUPPLIER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
02/24/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
520 FIRST STREET NORTHEAST
SARTELL, MN 56377
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
2 000 Continued From page 1
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETE
DATE
2 000
Compliance Monitoring, Licensing and
Certification Program, 3333 West Division St,
Suite 212, St Cloud, MN 56301.
21426 MN St. Statute 144A.04 Subd. 3 Tuberculosis
21426
Prevention And Control
(a) A nursing home provider must establish and
maintain a comprehensive tuberculosis
infection control program according to the most
current tuberculosis infection control guidelines
issued by the United States Centers for Disease
Control and Prevention (CDC), Division of
Tuberculosis Elimination, as published in CDC's
Morbidity and Mortality Weekly Report (MMWR).
This program must include a tuberculosis
infection control plan that covers all paid and
unpaid employees, contractors, students,
residents, and volunteers. The Department of
Health shall provide technical assistance
regarding implementation of the guidelines.
(b) Written compliance with this subdivision must
be maintained by the nursing home.
This MN Requirement is not met as evidenced
by:
Based on interview and documentation review,
the facility failed to ensure the millimeters of
induration for the tuberculin skin test (TST) were
documented for 1 of 5 residents (R369) and failed
to document the TST result identifying if it was
negative or positive for 4 of 5 residents (R369,
R310, R201, and R37). This had the potential to
Minnesota Department of Health
STATE FORM
6899
C4RT11
If continuation sheet 2 of 4
PRINTED: 03/01/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
COUNTRY MANOR HEALTH & REHAB CTR
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
B. WING _____________________________
00627
NAME OF PROVIDER OR SUPPLIER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
02/24/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
520 FIRST STREET NORTHEAST
SARTELL, MN 56377
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
21426 Continued From page 2
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETE
DATE
21426
affect all 159 residents.
Findings include:
R369 was admitted to the facility on 2/1/16,
according to an entry tracking record Minimum
Data Set (MDS) dated 2/1/16.
A Clinical Record of Immunizations indicated
R369 had a first step TST on 2/1/16, with a result
of negative, however, the millimeters (mm) of
induration was not documented. R369 had a
second step TST on 2/15/16, with a result of no
mm of induration, with no reading of positive or
negative. .
R310 was admitted to the facility on 1/24/16,
according to the admission MDS dated 1/30/16.
A Clinical Record of Immunizations indicated
R310 had a first step TST on 1/24/16, and the
second step on 2/9/16, both had results read as
no mm of induration, however, neither identified if
the results were positive or negative.
R201 was admitted to the facility on 1/28/16,
according to the admission MDS dated 2/4/16.
A Clinical Record of Immunizations indicated
R201 had a first step TST on 1/28/16, and the
second step TST on 2/12/16, both had results
read as no mm of induration, however, neither
identified if the results were positive or negative.
R67 was admitted to the facility on 1/25/16,
according to the admission MDS dated 1/31/16.
A Clinical Record of Immunizations indicated R67
had a first step TST on 1/25/16, and a second
step TST on 2/8/16, both had results read as no
Minnesota Department of Health
STATE FORM
6899
C4RT11
If continuation sheet 3 of 4
PRINTED: 03/01/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
COUNTRY MANOR HEALTH & REHAB CTR
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
B. WING _____________________________
00627
NAME OF PROVIDER OR SUPPLIER
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
02/24/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
520 FIRST STREET NORTHEAST
SARTELL, MN 56377
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
21426 Continued From page 3
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETE
DATE
21426
mm of induration, however, neither identified if
the results were positive or negative.
During an interview on 2/24/16, at 10:48 a.m.
registered nurse (RN)-A stated staff would be
educated on TST documentation to ensure they
are documenting the results of negative or
positive, and the mm of induration.
A facility policy TB [tuberculosis] Control Program
Overview dated 12/15, lacked direction on how to
document and interpret the results of a TST for
residents.
SUGGESTED METHOD OF CORRECTION:
The administrator or designee could review the
facility system in place to ensure residents TST
readings are documented as required by state
rule. The administrator or designee could
educate staff on the system in place, and monitor
TST results documented.
TIME PERIOD FOR CORRECTION: Twenty one
(21) days.
Minnesota Department of Health
STATE FORM
6899
C4RT11
If continuation sheet 4 of 4